Cognitive behavioural therapy (CBT) is like Marmite for many therapists. Some emphasize the research results which arguably show that it’s the “gold standard of the psychotherapy field” (David, Cristea and Hofmann, 2018). Others, like Richard House, see it as a “therapeutic technology” backed by a research regime that misses vital aspects of therapeutic practice; “subtlety, intuition, discernment and ‘the tacit’ in human relational experience” (2010).
Given that my original therapeutic training was with two of the most vehement critics of CBT – Richard House and Del Loewenthal – it seemed odd to some colleagues that I completed a Professional Certificate in CBT. One jokingly suggested that I’d “gone to the Dark side”!
At first CBT didn’t sit well with my existing approach, which is very much grounded in those qualities Richard extolled; subtlety, intuition and tacit embodied knowing. But I sensed that there was something of value here, notably because I’d unwittingly used CBT techniques to tackle my own anxiety in the past. Several years ago I started getting anxious about whether I’d locked the front door. I’d be about to cycle off to work when the thought would come: ‘Did I lock the door properly?’ My rational mind knew very well that I had: I’d been successfully locking my front door every day for years! But the doubt nagged at me. The first couple of times I went back to check and it was, of course, fine. But I knew this wasn’t right because I was pandering to my irrational concerns. So I stopped checking. Sometimes it was quite hard. That voice in my head said: ‘It’ll only take a second to check, and then you won’t have to worry any more.’ I countered that with reason: ‘There’s no need to check. I already know it’s fine’. That’s a classic CBT approach and it worked very well: The worry went away instead of growing into full blown OCD!
But CBT doesn’t work for everyone. I’ve had several clients tell me that they tried CBT and it just didn’t work for them. Typically their CBT was provided on the NHS and the therapist didn’t know any other way of working. Why bother to learn anything else when CBT is the “gold standard”? This is part of the reason why CBT has such a bad name amongst some therapists: CBT is presented as the solution in a ‘one size fits all’ approach.
There’s some evidence that CBT is becoming less effective. A paper from 2015 looked at 70 CBT trials and found that the impact of the treatment for depression was falling (Johnsen and Friborg). The authors suggest several possible reasons for this decline, with the most likely being a reduction in therapist competence. What made CBT so attractive to the NHS was that it can be done by the book. In theory anyone who knows how to follow a step-by-step guide and can demonstrate the exercises to a client can be CBT therapist. But we know from extensive research that technique contributes no more than about 20% to the outcome of therapy. Those vital elements that Richard House highlighted above – subtlety, intuition, discernment and tacit knowing – are much more important.
I’m pleased I persevered with CBT. My trainer – a therapist with many years of experience – emphasized that CBT works best when it’s used creatively by an empathic, open minded therapist. It also opens the door to further training with the ‘third wave’ of CBT that integrates it with mindfulness.
CBT isn’t just one more technique in my ‘tool box’: It’s more like another pattern to weave into the rich tapestry of my therapeutic practice. As Richard House points out, the key to good therapy is how it’s practised, not which techniques are used (ibid.). To put it more crudely, it’s not what you do, it’s the way that you do it!